funic presentation ultrasound

• Cord presentation
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At the time the article was last revised Joshua Yap had no financial relationships to ineligible companies to disclose.

• Funic presentation
• Cord (funic) presentation

A cord presentation (also known as a funic presentation or obligate cord presentation ) is a variation in the fetal presentation  where the umbilical cord points towards the internal cervical os or lower uterine segment.

It may be a transient phenomenon and is usually considered insignificant until ~32 weeks. It is concerning if it persists past that date, after which it is recommended that an underlying cause be sought and precautionary management implemented.

On this page:

Epidemiology, radiographic features, treatment and prognosis, differential diagnosis.

• Cases and figures

The estimated incidence is at ~4% of pregnancies.

Associations

Recognized associations include:

marginal cord insertion from the caudal end of a low-lying placenta

uterine fibroids

uterine adhesions

congenital uterine anomalies that may prevent the fetus from engaging well into the lower uterine segment

cephalopelvic disproportion

polyhydramnios

multifetal pregnancy

long umbilical cord

Color Doppler interrogation is extremely useful and shows cord between the fetal presenting part and the internal cervical os. However, unlike a vasa previa , the placental insertion is usually normal.

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As the complicating umbilical cord prolapse can lead to catastrophic consequences, most advocate an elective cesarean section delivery for persistent cord presentation in the third trimester 3 .

Complications

It can result in a higher rate of umbilical cord prolapse .

For the presence of umbilical cord vessels between the fetal presenting part and the internal cervical os on ultrasound consider:

vasa previa

• 1. Ezra Y, Strasberg SR, Farine D. Does cord presentation on ultrasound predict cord prolapse? Gynecol. Obstet. Invest. 2003;56 (1): 6-9. doi:10.1159/000072323 - Pubmed citation
• 2. Kinugasa M, Sato T, Tamura M et-al. Antepartum detection of cord presentation by transvaginal ultrasonography for term breech presentation: potential prediction and prevention of cord prolapse. J. Obstet. Gynaecol. Res. 2007;33 (5): 612-8. doi:10.1111/j.1447-0756.2007.00620.x - Pubmed citation
• 3. Raga F, Osborne N, Ballester MJ et-al. Color flow Doppler: a useful instrument in the diagnosis of funic presentation. J Natl Med Assoc. 1996;88 (2): 94-6. - Free text at pubmed - Pubmed citation
• 4. Bluth EI. Ultrasound, a practical approach to clinical problems. Thieme Publishing Group. (2008) ISBN:3131168323. Read it at Google Books - Find it at Amazon

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• Variation in fetal presentation
• Vasa praevia
• Umbilical cord prolapse
• Vasa previa

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INTRODUCTION

Funic or cord presentation is defined as one or more loops of umbilical cord floating between the fetal presenting part and the internal cervical os, typically with the membranes are intact. With normal amniotic fluid volume, funic presentation is often a dynamic process that can appear and disappear with fetal movement, especially earlier in gestation. The clinical significance of funic presentation is that as gestational age advances and the fetal head becomes engaged, the cord can become wedged between the uterine wall and fetal presenting part, creating an occult or overt prolapse upon membrane rupture.

Of note, an alternative nomenclature has been proposed whereby classification is based on the positional relationship among the cord, the fetal presenting part, and the cervix [ 1 ]. In this system, "cord prolapse" refers to an umbilical cord that has prolapsed past the fetal presenting part and beyond the internal cervical os, "cord presentation" refers to an umbilical cord ahead of the fetal presenting part but above the internal cervical os, and "compound cord presentation" refers to both the cord and fetus presenting above the internal cervical os. Any of the three clinical scenarios can occur with either intact or ruptured membranes.

This topic will discuss the frequency, pathogenesis, risk factors, clinical findings, diagnosis, management, potential prevention, and outcome of umbilical cord prolapse.

Umbilical cord constriction can be due to intrinsic or extrinsic mechanisms. Constriction may lead to different degrees of flow limitation in the cord"s vessels, which can be demonstrated by pulsed Doppler flow studies. Intrinsic constriction is characterized by localized absence of Wharton"s jelly, leading to narrowing of the cord, thickening of the vascular walls and narrowing of the vascular lumens. In this setting, fetal death might occur due to acute vasospasm, acute oligohydramnios and uterine contraction, or an obliterating thrombus (10). Extrinsic constriction can be caused by:

Occasionally loops of cord may lie between the lower uterine segment and the presenting part (cord or funic presentation). This is important to recognize as it predisposes to cord prolapse and possible fetal death when the membranes rupture. Funic presentation is more common with malpresentations (especially breech and transverse lie).

• Transient and usually insignificant prior to 32 weeks. If this is persistent one must look for a cause.
• Marginal cord insertion from the caudal end of a low-lying placenta.
• Uterine fibroids / Uterine adhesions.
• Congenital uterine anomalies that may prevent the fetus from engaging well into the lower uterine segment.
• Cephalopelvic disproportion.
• Polyhydramnios.
• Multiple gestations.
• Increased umbilical cord length.
• Prolapse of the cord occurs in 0.5% of cases.
• High perinatal mortality rate due to cord compression (1).
• Selbing A. Umbilical cord compression diagnosed by means of ultrasound. Acta Obstet Gynecol Scand 1988;67:565-567.
• Hales ED, Westney LS. Sonography of occult cord prolapse. JCU 1984;12:283-285.
• Dudiak CM, Salomon CG, Posniak HV et.al. Sonography of the umbilical cord. Radiographics 1995;15:1035-1050.
• Johnson RL, Anderson JC, Irsik RD et.al. Duplex ultrasound diagnosis of umbilical cord prolapse. J Clin Ultrasound 1987;15:282-284.
• Kanayama MD, Gaffey TA, Ogburn PL Jr. Constriction of the umbilical cord by an amniotic band, with fetal compromise illustrated by reverse diastolic flow in the umbilical artery. A case report. J Reprod Med 1995 Jan;40(1):71-73.
• Boughizane S, Zhioua F, Jedoui A, Kattech R, Gargoubi N, Srasra M, Ben Romdhane K, Meriah S. Swallowing of an amniotic string by a fetus at term. J Gynecol Obstet Biol Reprod (Paris) 1993;22(4):409-410.
• Heifetz SA. Strangulation of the umbilical cord by amniotic bands: report of 6 cases and literature review. Pediatr Pathol 1984;2(3):285-304.
• Reles A, Friedmann W, Vogel M, Dudenhausen JW. Intrauterine fetal death after strangulation of the umbilical cord by amniotic bands. Geburtshilfe Frauenheilkd 1991 Dec;51(12):1006-1008.
• Sherer DM, Anyaegbunam A. Prenatal ultrasonographic morphologic assessment of the umbilical cord: a review. Part I. Obstet Gynecol Surv 1997 Aug;52(8):506-514
• Hallak M, Pryde PG, Qureshi F, Johnson MP, Jacques SM, Evans MI. Constriction of the umbilical cord leading to fetal death. A report of three cases. J Reprod Med 1994 Jul;39(7):561-565.

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Color flow Doppler: a useful instrument in the diagnosis of funic presentation.

Color Doppler sonography offers the opportunity to evaluate the umbilical cord and to study blood velocity wave forms within the cord. Funic (cord) presentation can be diagnosed unequivocally with color Doppler sonography. Because funic presentation is likely to be the harbinger of cord prolapse, the morbidity and mortality associated with cord prolapse can be prevented if funic presentation is diagnosed before membrane rupture. This article describes the first case in the obstetric literature of funic presentation diagnosed with color Doppler sonography. The potential complications associated with cord prolapse were avoided with a cesarean section.

Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (560K), or click on a page image below to browse page by page. Links to PubMed are also available for Selected References .

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The Unique Burial of a Child of Early Scythian Time at the Cemetery of Saryg-Bulun (Tuva)

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Pages:  379-406

In 1988, the Tuvan Archaeological Expedition (led by M. E. Kilunovskaya and V. A. Semenov) discovered a unique burial of the early Iron Age at Saryg-Bulun in Central Tuva. There are two burial mounds of the Aldy-Bel culture dated by 7th century BC. Within the barrows, which adjoined one another, forming a figure-of-eight, there were discovered 7 burials, from which a representative collection of artifacts was recovered. Burial 5 was the most unique, it was found in a coffin made of a larch trunk, with a tightly closed lid. Due to the preservative properties of larch and lack of air access, the coffin contained a well-preserved mummy of a child with an accompanying set of grave goods. The interred individual retained the skin on his face and had a leather headdress painted with red pigment and a coat, sewn from jerboa fur. The coat was belted with a leather belt with bronze ornaments and buckles. Besides that, a leather quiver with arrows with the shafts decorated with painted ornaments, fully preserved battle pick and a bow were buried in the coffin. Unexpectedly, the full-genomic analysis, showed that the individual was female. This fact opens a new aspect in the study of the social history of the Scythian society and perhaps brings us back to the myth of the Amazons, discussed by Herodotus. Of course, this discovery is unique in its preservation for the Scythian culture of Tuva and requires careful study and conservation.

Keywords: Tuva, Early Iron Age, early Scythian period, Aldy-Bel culture, barrow, burial in the coffin, mummy, full genome sequencing, aDNA

Information about authors: Marina Kilunovskaya (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Vladimir Semenov (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Varvara Busova  (Moscow, Russian Federation).  (Saint Petersburg, Russian Federation). Institute for the History of Material Culture of the Russian Academy of Sciences.  Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail:  [email protected] Kharis Mustafin  (Moscow, Russian Federation). Candidate of Technical Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Irina Alborova  (Moscow, Russian Federation). Candidate of Biological Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Alina Matzvai  (Moscow, Russian Federation). Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected]

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Savvino-storozhevsky monastery and museum.

Zvenigorod's most famous sight is the Savvino-Storozhevsky Monastery, which was founded in 1398 by the monk Savva from the Troitse-Sergieva Lavra, at the invitation and with the support of Prince Yury Dmitrievich of Zvenigorod. Savva was later canonised as St Sabbas (Savva) of Storozhev. The monastery late flourished under the reign of Tsar Alexis, who chose the monastery as his family church and often went on pilgrimage there and made lots of donations to it. Most of the monastery’s buildings date from this time. The monastery is heavily fortified with thick walls and six towers, the most impressive of which is the Krasny Tower which also serves as the eastern entrance. The monastery was closed in 1918 and only reopened in 1995. In 1998 Patriarch Alexius II took part in a service to return the relics of St Sabbas to the monastery. Today the monastery has the status of a stauropegic monastery, which is second in status to a lavra. In addition to being a working monastery, it also holds the Zvenigorod Historical, Architectural and Art Museum.

Belfry and Neighbouring Churches

Located near the main entrance is the monastery's belfry which is perhaps the calling card of the monastery due to its uniqueness. It was built in the 1650s and the St Sergius of Radonezh’s Church was opened on the middle tier in the mid-17th century, although it was originally dedicated to the Trinity. The belfry's 35-tonne Great Bladgovestny Bell fell in 1941 and was only restored and returned in 2003. Attached to the belfry is a large refectory and the Transfiguration Church, both of which were built on the orders of Tsar Alexis in the 1650s.  

To the left of the belfry is another, smaller, refectory which is attached to the Trinity Gate-Church, which was also constructed in the 1650s on the orders of Tsar Alexis who made it his own family church. The church is elaborately decorated with colourful trims and underneath the archway is a beautiful 19th century fresco.

Nativity of Virgin Mary Cathedral

The Nativity of Virgin Mary Cathedral is the oldest building in the monastery and among the oldest buildings in the Moscow Region. It was built between 1404 and 1405 during the lifetime of St Sabbas and using the funds of Prince Yury of Zvenigorod. The white-stone cathedral is a standard four-pillar design with a single golden dome. After the death of St Sabbas he was interred in the cathedral and a new altar dedicated to him was added.

Under the reign of Tsar Alexis the cathedral was decorated with frescoes by Stepan Ryazanets, some of which remain today. Tsar Alexis also presented the cathedral with a five-tier iconostasis, the top row of icons have been preserved.

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The Nativity of Virgin Mary Cathedral is located between the Tsaritsa's Chambers of the left and the Palace of Tsar Alexis on the right. The Tsaritsa's Chambers were built in the mid-17th century for the wife of Tsar Alexey - Tsaritsa Maria Ilinichna Miloskavskaya. The design of the building is influenced by the ancient Russian architectural style. Is prettier than the Tsar's chambers opposite, being red in colour with elaborately decorated window frames and entrance.

At present the Tsaritsa's Chambers houses the Zvenigorod Historical, Architectural and Art Museum. Among its displays is an accurate recreation of the interior of a noble lady's chambers including furniture, decorations and a decorated tiled oven, and an exhibition on the history of Zvenigorod and the monastery.

Palace of Tsar Alexis

The Palace of Tsar Alexis was built in the 1650s and is now one of the best surviving examples of non-religious architecture of that era. It was built especially for Tsar Alexis who often visited the monastery on religious pilgrimages. Its most striking feature is its pretty row of nine chimney spouts which resemble towers.

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